Pasquini L, Parness I A, Colan S D, Wernovsky G, Mayer J E, Sanders S P
Department of Cardiology, Children's Hospital, Boston, MA 02115.
Circulation. 1993 Sep;88(3):1136-41. doi: 10.1161/01.cir.88.3.1136.
An intramural coronary is an uncommon but potentially significant risk factor for transfer of the coronary arteries as part of the arterial switch operation for transposition of the great arteries. Preoperative diagnosis is advantageous because it helps prevent accidental injury to the intramural coronary artery during transection of the aortic root and excision of the coronary artery ostium from the aorta. Therefore, we investigated the reliability of two-dimensional echocardiography for detecting an intramural coronary artery in infants with d-transposition of the great arteries.
All infants with d-transposition of the great arteries who underwent echocardiography and primary surgical repair at this institution between January 1987 and June 1992 were identified by search of the cardiology data base. From this group, all patients diagnosed with an intramural coronary artery were identified by review of the echocardiographic, surgical, and autopsy reports. Among 435 infants with transposition, 29 infants were diagnosed as having an intramural coronary artery. In 27 cases, the diagnosis was confirmed at surgery or autopsy, and there were two false-positive echocardiographic diagnoses (specificity, 99.5%). Twenty of the 27 patients with an intramural coronary artery were correctly diagnosed prospectively by echocardiography (sensitivity, 75%), including 17 of 23 patients with an intramural left coronary artery or left anterior descending coronary artery and 3 of 4 patients with an intramural right coronary artery. Two primary diagnostic criteria were identified: a major coronary artery arising from the contralateral septal sinus, near the usually intercoronary commissure, and a course for this vessel within the posterior aortic wall between the great arteries, creating a "double-border" appearance. Retrospective review using these criteria identified 26 of the 27 intramural arteries with no false-positive diagnoses.
We conclude that coronary echocardiography is a very promising technique for detecting an intramural coronary artery in transposition of the great arteries. Careful prospective application of the identified diagnostic criteria should greatly improve the diagnostic accuracy.
壁内冠状动脉是大动脉转位动脉调转术中转位冠状动脉的一种罕见但潜在的重要危险因素。术前诊断具有优势，因为它有助于防止在主动脉根部横断和从主动脉切除冠状动脉开口时意外损伤壁内冠状动脉。因此，我们研究了二维超声心动图检测大动脉d型转位婴儿壁内冠状动脉的可靠性。
通过检索心脏病数据库，确定了1987年1月至1992年6月期间在本机构接受超声心动图检查和一期手术修复的所有大动脉d型转位婴儿。从该组中，通过回顾超声心动图、手术和尸检报告，确定了所有诊断为壁内冠状动脉的患者。在435例转位婴儿中，29例被诊断为有壁内冠状动脉。27例手术或尸检确诊，2例超声心动图诊断为假阳性（特异性99.5%）。27例壁内冠状动脉患者中，20例通过超声心动图前瞻性正确诊断（敏感性75%），包括23例壁内左冠状动脉或左前降支冠状动脉患者中的17例以及4例壁内右冠状动脉患者中的3例。确定了两个主要诊断标准：一条主要冠状动脉起源于对侧间隔窦，靠近通常的冠状动脉间联合处，且该血管在大动脉之间的主动脉后壁内走行，形成“双边”外观。使用这些标准进行回顾性分析，在27例壁内动脉中识别出26例，无假阳性诊断。
我们得出结论，冠状动脉超声心动图是检测大动脉转位壁内冠状动脉的一项非常有前景的技术。仔细前瞻性应用已确定的诊断标准应能大大提高诊断准确性。
